<form id="add-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Nametext')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-nametext" data-rule="required" class="form-control" name="row[nametext]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('User_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-user_id" data-rule="required" data-source="user/user/index" data-field="nickname" class="form-control selectpage" name="row[user_id]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Coupon_clinic_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-coupon_clinic_id" data-rule="required" data-source="coupons/clinic/index" class="form-control selectpage" name="row[coupon_clinic_id]" type="text" value="">
        </div>
    </div>
   
   
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Authorizedata')}:</label>
        <div class="col-xs-12 col-sm-8">
            
            <div class="radio">
            {foreach name="authorizedataList" item="vo"}
            <label for="row[authorizedata]-{$key}"><input id="row[authorizedata]-{$key}" name="row[authorizedata]" type="radio" value="{$key}" {in name="key" value="1"}checked{/in} /> {$vo}</label> 
            {/foreach}
            </div>

        </div>
    </div>
    
     <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Reasontext')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-reasontext" data-rule="" class="form-control" rows="5" name="row[reasontext]" cols="50"></textarea>
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>